Health care challenges in Minnesota tied to access, insurance, says physician advocates
By Andrea Parrott
Twin Cities Daily Planet, Dec. 24, 2012
After daily witnessing situations in which patients suffered or had to make decisions detrimental to their health due to difficulties in accessing health care, Dr. Elizabeth Frost and Dr. Ann Settgast had enough. They felt they had to do something that would allow everyone to have health insurance and so, access to health care. The two decided to found the Minnesota chapter of Physicians for a National Health Program (PNHP).
PNHP is a national non-profit organization whose members advocate for single payer health care. The idea of single payer health care is that instead of people paying fees to a private health insurance company, they will pay one fund. Hospitals, doctors, and other health providers would then receive payment from that one fund. Dr. Settgast explained single payer in this way: “Some people use an analogy of 'Medicare of all' as a synonym for single payer… It’s an example of a fund where everyone pays into the fund and then that fund pays for health care and private deliverers of health care. So Medicare is like a little micro single payer."
Twin Cities Daily Planet spoke with the doctors, asking them about the state of health care in Minnesota. The edited interview is below.
What are some personal experiences that led you to advocate for a single payer health program?
Dr. Settgast: That’s a great question that could take me like 12 hours to answer. I’m a primary care doctor so I take care of patients on a daily basis. Every single day I see reasons why we need single payer. A recent one would be a woman who I took care of—a Vietnamese woman in her early 60s who came in and I diagnosed her with rheumatoid arthritis, which is terrible—she had terrible swelling of her hand joints. Really deforming joint disease. She was a full-time employee of a company and her husband worked full time as well. Got her to the rheumatologist. Got her on the right drugs. Her joints totally improved. Her pain was eliminated. She was fully functional. Everything was great.
And then, she just didn’t show up for like two or three years. One day she just shows up on my schedule… So I came into the room. She’s a tiny little woman and from the door, I could see her joint was like the size of a golf ball—like hugely swollen. I said, I’ll just change her name, I said “Lynn, what happened? Where have you been?” Since I had seen her, she got laid off from her job and her husband died. And she was only 63 at the time that this happened… She didn’t have access to health care so she just had to stop her drugs, stop seeing her rheumatologist and her joints deteriorated… I didn’t realize, but she had turned 65, so she was back. And it’s disgusting because this woman’s hand is ruined and it’s totally preventable. We see this stuff every single day. And it’s inhumane and it’s disgusting as a physician when all you care about is taking care of sick people to see people not access care.
Dr. Frost: A daily basis there are stories… Yesterday I had a patient who stopped her birth control and now is pregnant. I also today had somebody who had psoriasis… they haven’t had it treated in almost a year now because they don’t have insurance… Again, again, and again, you’re looking at somebody and apologizing for our medical system. “That’s really unfair. I’m sorry that happened to you.” You can’t just keep doing that again and again. You have to find some other outlet to feel like you’re making a difference on a larger level.
What do you see as the main health care policy issues in Minnesota?
Dr. Settgast: We are leading the nation in the number of individuals with high deductible health insurance plans. The idea is that this would somehow promote personal responsibility. You have a high deductible so you’re not going to go to the doctor unless you really need to because you’re going to be spending your own money. But what that says is that you’re relying on people who aren’t doctors to decide whether they need medical care or not—is problematic right there. That’s our job: to say, "No, this is not something serious, you’re OK." People shouldn’t be relied on to do that at home. But then the other issue that we know, there is actually good data showing that the higher your deductible, the less care you receive. And there’s no way to know that that care isn’t needed. You’re much more likely to see conditions being under-managed or undiagnosed. People just aren’t going to the office when they’re sick…
Dr. Frost: I think a big huge policy thing that’s really going on in Minnesota right now, of course, is the exchanges and figuring out how to set up the exchanges under the Affordable Care Act—that’s huge. That’s going to take up a lot of energy in the next year or two, but I don’t know how much it’s really going to solve the problem.
Dr. Settgast: It’s not going to solve it because all you’re doing is adding this level of administrative complexity when now people can go shopping in this exchange to get their private health insurance. It might help some people to get some policy, but it’s not designing the system so that it will work. It’s adding more complexity to an already chaotic system… You still have these huge billing departments having to bill multiple payers and you’re still having insurance companies take all this money off the top… for functions that have nothing to do with health care. There’s still a huge amount of waste still in the system and we haven’t done anything to change that.
What are some of the main health policy issues that you see facing the nation?
Dr. Frost: I think Minnesota is a little bit ahead of the rest of the nation in the area that we’re talking about… Like we already offer Medicaid to adults without children.
Dr. Settgast: Our Medicaid eligibility rules are much better here… I have a brother in Indiana… if he was here he would qualify for coverage…
Dr. Frost: We’re talking a lot about how health care is paid for when we do single payer… I think Minnesota has some of the largest health care disparities. I know that education is the worst in the nation in terms of disparities… I don’t know how we compare to other states in terms of health care, but I have a feeling it’s not very good. One of the things that really distresses me a lot is especially the Native Americans have terrible, terrible health care statistics… It’s really, really sad and that’s a population I work with a lot.
Dr. Settgast: The problems in the nation are the same as the problems here: uninsurance, underinsurance, people not having access to care. That’s all in all of the states.
Dr. Frost: Of course the biggest problem is the insurance industry… It’s not like the politicians are in charge and they’re guiding the system—no, they need to figure out what the [insurance] industry might accept and then work within those boundaries… Our politicians are controlled pretty much by the industry… The evidence for a single payer system is so ridiculously strong, it’s really amazing that we weren’t able to do more with the Affordable Care Act. It’s really quite astounding—that the Affordable Care Act is such a big deal and it does so little… one of things that was not allowed to be on the table, was not allowed to be discussed at all was the idea that the government would purchase drugs for our elderly… Now there’s like a gazillon Medicare Part D plans. Each one of those little plans doesn’t have the purchasing power to drive down the price of drugs.
Dr. Settgast: We see the patients who don’t take their medicines, or they take them every other day because they have to make them last.
What are some of the main challenges to making changes in health policy?
Dr. Settgast: The health insurers. Because if you look at the polling data, the public supports single payer, physicians support single payer… We know you can cover everyone for less cost and give everyone high quality coverage.
What happens in the U.S. is if I’m the doctor and I see 20 patients in a day and I diagnose them all with the same thing. Let’s say they all have diabetes or uncontrolled sugar. Every patient, depending on their payer, may pay my clinic a different fee because all the payers, the insurance companies, are negotiating with the all the clinics separately… so it’s hugely complicated, which is part of the cost—all these contract negotiations because everybody gets a different deal and so every patient pays differently… It’s so unequal. And then if you’re uninsured and you come in, you have a totally different cost than what the insurance pays in the next room.
Dr. Frost: It’s totally unfair. Because you’re uninsured, you have to pay the full price… if you’re totally uninsured you have to pay the $300 while the insurance pays $200, and Medicaid might pay $175 and Medicare might pay $215…
What progress do you see in addressing health disparities in Minnesota?
Dr. Settgast: I personally think it’s crazy to try and address health disparities without having a system that covers everyone. I mean how can you really expect to decrease disparities if you have whole portions of the population that don’t have any access to the system? You can’t do things on a population level if you’re leaving 10 percent of the people out… I mean obviously having a single payer doesn’t eliminate all health care disparities because a lot of health care disparities isn’t necessarily access to the system, but it’s the first step… I mean, how are they going to stand on equal footing in terms of their diabetes control or their hypertension control if they don’t have a doctor because they don’t have health insurance?
Dr. Frost: I think it’s important to differentiate between health disparities and health care disparities because health disparities are, a lot of them are socially determined. So if you don’t have a grocery store in the area… that will make it a lot harder to eat well… So I think separating those two things are important, but in terms of access to health care, I see again and again and again… somebody gets out of Medicaid and gets a job and loses their insurance so they can’t see you anymore. So once you get back… on your feet, you get back into the system, you can’t treat those diseases that you’ve been treating… So it’s that inequality in the health care system, the injustice in the health care system is what makes me so angry, and it’s because I see it every day.
© 2012 Andrea Parrott